DIABETES EDUCATION ORDER FORM. Fax to Diabetes Program: (510) DIABETES SELF-MANAGEMENT TRAINING ORDERS. Sweet Success Program for Gestational Diabetes (GDM) …
DIABETES EDUCATION ORDER FORM
Fax to Diabetes Program: 510 739-0687
Date:__________
|PATIENT INFORMATION |
|Last name:____________________________ |First:_______________________ |
|Date of birth:__________SSN:____________|Home phone:__________________________ |
|Address:_____________________________ |Work phone____________Cell:____________ |
|City:_____________________Zip:________ |Primary Language:______________________ |
DIAGNOSIS check all that apply
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|DIABETES SELF-MANAGEMENT TRAINING ORDERS |
| |Sweet Success Program for Gestational Diabetes GDM |
| |Oral Glucose Tolerance date_____, results mg/dl: fasting____; 1 hour____; 2 |
| |hour____; 3 hour___
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| |If glucose patterns above target/high risk range, refer to first available |
| |endocrinologist or:__________ |
| |Perform/follow-up with 6 week postpartum Oral Glucose Tolerance Test 2 hour |
| |75-gm glucose |
| |Complete Diabetes Program |
| |10 hours/national standard |
| |Individual Diabetes Counseling, focus:______________________________________ |
| |One-to-one education when group classes are not appropriate Must check special |
| |needs: |
| |___Language, ___Vision, ___Hearing, ___Physical, ___Cognitive Impairment, |
| |Other_____________ |
| |Medication Instruction |
| |Orals: antidiabetics:________________________________________________________ |
| |Insulin: stop oral medications?
____Yes____No |
| |Start Insulin: Rx_____________________________________________________________ |
| | Adjust Insulin:___________________for fasting/pre-meal target range |
| |of_________mg/dl |
| |Insulin-to-carbohydrate ratio: take____units of__________for____grams of |
| |carbohydrate |
| |Other:_____________________________________________________________________ |
| |Insulin Pump Training |
| |Basal:_______Mealtime bolus:______Correction bolus:______ Insulin sensitivity |
| |factor:______ |
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|ATTACH COPIES OF RECENT LABS: glucose, A1C, Chem Panel, and lipids if available |
|Perform A1C on initial assessment and capillary glucose as needed; |
|For non-GDM patients, perform urine microalbumin and a 3-month follow-up A1C |
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|PHYSICIAN NAME:_________________________SIGNATURE:____________________________ |
|Address:____________________________________________ |City:______________Zip:_______|
|Phone:_______________________Fax:___________________ |UPIN _____________________ |
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Source:thechristhospital.com
